Wash. Admin. Code § 284-96-012 - Discretionary clauses prohibited

Current through Register Vol. 22-07, April 1, 2022

(1) No disability insurance policy may contain a discretionary clause. "Discretionary clause" means a provision that purports to reserve discretion to an insurer, its agents, officers, employees, or designees in interpreting the terms of a policy or deciding eligibility for benefits, or requires deference to such interpretations or decisions, including a provision that provides for any of the following results:
(a) That the insurer's interpretation of the terms of the policy is binding;
(b) That the insurer's decision regarding eligibility or continued receipt of benefits is binding;
(c) That the insurer's decision to deny, modify, reduce or terminate payment, coverage, authorization, or provision of health care service or benefits, is binding;
(d) That there is no appeal or judicial remedy from a denial of a claim;
(e) That deference must be given to the insurer's interpretation of the contract or claim decision; and
(f) That the standard of review of an insurer's interpretation of the policy or claim decision is other than a de novo review.
(2) Nothing in this section prohibits an insurer from including a provision in a policy that informs an insured that as part of its routine operations the insurer applies the terms of its policies for making decisions, including making determination regarding eligibility, receipt of benefits and claims, or explaining its policies, procedures, and processes.

Notes

Wash. Admin. Code § 284-96-012

Statutory Authority: RCW 48.20.450, 48.20.460, 48.30.010, 48.44.050, 48.46.200, 48.02.060, 48.18.110, 48.44.020, and 48.46.060. 09-16-128 (Matter No. R 2008-25), § 284-96-012, filed 8/5/09, effective 9/5/09.

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